How mental health apps can accelerate the psychiatric prescribing cascade

By Judith Garber | March 18, 2022

Mental health care is notoriously inaccessible in the U.S. Despite the inclusion of “mental health parity” rules in the Affordable Care Act to ensure that these services are covered in health plans, many plans don’t comply. For those with public insurance, it’s even harder to access services because not all providers accept Medicaid.

Apps that connect people to mental health providers have been seen as a way to improve needed access to these services. However, a recent Bloomberg investigation of the popular mental health app Cerebral finds evidence of harmful overtreatment. Cerebral connects users to a therapist and a psychiatric nurse practitioner for a monthly fee.

Former Cerebral employees interviewed for the article said the company prioritized quantity over quality, pushing more patient visits, shorter appointments, and more prescriptions. In one case, a Cerebral user was prescribed three antidepressants, an anticonvulsant, and an antipsychotic over the course of three months. One of these medications was prescribed after just an 18-minute video visit. She began having concerning side effects from the medications. After she reported having auditory hallucinations, her Cerebral nurse practitioner determined she needed in-person services and terminated her cerebral treatment.

Cerebral makes it especially easy to access ADHD medication, and advertises on social media as a platform to help those with undiagnosed ADHD to get treatment. However, former nurses for Cerebral told Bloomberg they “feared that they were fueling a new addiction crisis” by making Adderall and other amphetamines so easy to get.

Watchdog group Media Matters recently warned that advertisements for Cerebral and other mental health apps are “capitalizing on the TikTok phenomenon of ADHD self-diagnosis.” For example, one of these ads encourages female users who are “spacey, forgetful, or chatty” to consider they may have ADHD and seek a diagnosis.

Cerebral is not the first app to circumvent the traditional health care system to seemingly “improve access.” Companies like Hims, Kick, and Roman promise an easier way to access prescription drugs for conditions such as hair loss, erectile dysfunction, and anxiety by connecting directly with doctors online, who prescribe medications that are mailed directly to the customer. Experts have raised concerns with these apps about off-label prescribing, too-short patient visits, and lack of regulation in the industry.

In the case of Cerebral, overmedication may also be an unintended consequence of telehealth rules adopted during the pandemic. Previously, federal rules required that patients meet with a provider in person before receiving a prescription for amphetamines or benzodiazepines.

The medical app world is currently a “wild west” with little regulation. It appears that Cerebral and other mental health apps are capitalizing on the demand for services and the popularity of social media, but without any guardrails there is a high risk of overdiagnosis and overmedication. We clearly need more regulation, but it’s worth noting that these apps would not be so popular if in-person therapy and other mental health services were more easily accessible.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.